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chronic pancreatitis long case presentation
1.
Presented by Dr.
Amit kumar Shah ( Intern Doctor) Department of Surgery TMC & RCH
2.
Particulars of the
patient Name:Ms.SafuraBegam Age:38years Sex:Female Address:Kalupuri,kahaloo,bogura Maritalstatus: Married Religion :Islam Dateofadmission:14/11/22@5.5pm Dateofexamination:17/11/22@10.30am
3.
Chief complaints Recurrentpainintheupperabdomenfor3years
4.
History of present
illness Accordingtothestatement ofpatientShewas reasonablywell 3yearsbacktheshedeveloped recurrentpainintheepigastrium whichwas constantdullachinginnature,radiatingtoback, aggravatedbytakingfattyfoodand releived by bendingforwardandmedication. Thepainhadno periodicity. Thepainwassometime associatedwith nauseaandvomittingandcontainedundigested foodparticles.
5.
Forlast1yearwithanepisodes ofabdominalpain, noticedpassageofgreasystools,2-3episodes/day, normalvolume, nonfoulsmelling,
associated with oildroplet,difficulttoflushwhichisnotassociated withabdominalbloatingsensationandflatulence. Insomeoccasionthepainbecomesudden,severe andagonizinginnatureanddidn’trelieved by takinganalgesic
6.
Forthatreasonshewasadmittedtohospital3times andwastreatedconservatively. Shegavenohistory offever, jaundice,heartburn,chestpain,respiratory distress,nohistoryofNSAIDbeforetheonsetof pain,haematemesis
ormelenaorpassageofloose stool.Sheisnormotensive anddiabetic.Herbowel andbladderhabitisnormal.
7.
History of past
illness HistoryofDMforlast7years,Nonhypertensive
8.
Treatment History Shewasadmitted inlocalupazilla
hospital3times andwastreatedconservatively.
9.
Family History Sheis3rd issueofanon-consanguinusmarriage andevery
familymember arehealthyandaliveand havenosimilar healthissues
10.
Personal history She is
non-alcoholic, non smoker but betel nut chewer . She is accustomed to normal bengali diet.
11.
Allergic history Sheisnotallergic any
knowdrugs
12.
Menstrual history MC: regular28+/-2 MF:normal MP:5to7days Obstetric
History 1alivechildof18yearsmale
13.
General Examination Appearance:illlooking Bodybuilt:below average Cooperation:cooperative Decubitus
:onchoice Nutritionalstatus:below average Anemia:absent Jaundice:absent
14.
Cyanosis:absent Clubbing:absent Dehydration:moderatelydehydrated Edema:absent Koilonychia:absent Leuconychia:absent
15.
Pulse: 122/min Bp:120/70mmhg Temp:N RR:16/min Lymphnode:notenlagred Herniaorifice:intact
16.
Alimentary examination Oralcavity,gum,teeth –appearednormal Oninspection: Abdomenwasnormalinshape,umblicus
centrally placedinverted. Allquadrantmovesequallywith respirationandisthoraco-Abdominal.Novisible lumpinanyofthequadrantnorwasanyswelling at hernialsite.
17.
Onsuperficial palpation:localtemperaturewas normal,tenderness waspresent
inepigastrium, muscle guardandmusclerigiditywerepresentin epigastric region. Ondeeppalpation: Liver, spleen isnotpalpable.Bothkidneyarenot palpableorballotable. Fluidthrillwasabsent. Murphy’ssign:negative
18.
Onpercussion: Percussionnotewastympanic alloverthe abdomen.Shiftingdullness wasabsent. Onauscultation: bowelsoundwaspresentandnoanyaddedsound.
19.
Cardiovascularexaminationrevels pulse122/min, whichisnormalinrhythm,allperipherypulseare palpable. Respiratory,nervoussystemandothersystem examinationrevels noabnormalities.
20.
Silent features Misssofurabegum38yearsolddiabetic, non hypertensive
ladyhailingfrom kahalooBoguraand gotadmitted toTMCandRCHwithacomplaintof recurrentpainintheepigastrium for3years.then shedeveloped recurrentpainintheepigastrium whichwasconstantdullachinginnature,radiating toback,
21.
aggravatedbytakingfattyfoodand releived by bendingforwardandmedication.
Thepainhadno periodicity. Thepainwassometime associatedwith nauseaandvomittingandcontainedundigested foodparticles. Forlast1yearwithanepisodes of abdominalpain,noticedpassageofgreasystools, 2-3episodes/day,normalvolume,nonfoulsmelling, associatedwithoildroplet,
22.
difficulttoflushwhichisnotassociated with abdominalbloatingsensationandflatulence. In someoccasionthepainbecomesudden,severeand agonizinginnatureanddidn’trelieved
bytaking analgesic. Forthatreasonshewasadmittedto hospital3times andwastreatedconservatively.
23.
Shegavenohistoryoffever,jaundice,heartburn, chestpain,respiratorydistress,nohistoryofNSAID beforetheonsetofpain,haematemesis ormelena orpassageofloosestool.Sheis normotensiveand diabetic.Herbowelandbladderhabitisnormal.
24.
Onexaminationsheisill-looking moderately dehydrated,anoxious,tachycardiac(pulse122/min) withoutpallororjaundice,tenderness waspresent inepigastrium,
muscle guardandmuscle rigidity werepresentinepigastric region.Soitislikely due tochronicpancreatitis.
25.
26.
Chronicpancreatitis
27.
Differential Diagnosis PepticulcerDisease Chroniccholecystitis
28.
Investigation Testtoestablishthediagnosis Ultrasound CT(mayshowatrophy,
calcification,orductaldilatation) MRCP EndoscopicUltrasound Testforpancreaticfunction:1)collectionofpurepancreaticjuiceafter secretininjection(itisgoldstanderbutinvasiveandseldomused 2)Faecalpancreaticelastase Testofanatomypriortosurgery: MRCP
29.
INVESTIGATION Investigations Findings 1. CBC
HB:12.1gm/dL WBC count: 11,300/ccmm ESR: 50mm in 1st hour PC: 321000/ccmm 2. Urine R/E Pus cell: 5-7/HPF Epithelial cell: plenty 3. Serum creatinine 0.9mg/dL 4.RBS 216mg/dL
30.
Investigation for diagnosis: Ultrasonography
of whole abdomen: showingdilatedmajor pancreaticductwithmultiple calculiandfeaturesof chronicpancreatitis
31.
MRCP : Showing chronic calcificat ion with acute exacerab ation.
32.
Confirm Diagnosis Chronicpancreatitisduetopancreaticduct calculi
33.
Treatment 1. Conservative management
wasgiven afterthe clinical diagnosisofpatient. 2. Interventioninchronicpancreatitis: ENDOSCOPICTHERAPY Dilatationorstenting ofpancreaticductstrictures Removalofcalculi(mechanical orlithotripsy) Drainageofpseudocysts
34.
SURGICALMETHOD: Partialpancreaticresection, preserving the duodenum Pancreaticojejunostomy
35.
Thank You
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